UM Case Manager

Position: UM Case Manager

UM Case Manager implements the effective and best practices of Utilization Management. The UM Case Manager will provide high quality medical care review and service by appropriately applying the Milliman Care Guidelines, Health Plan and CMS/DMHC clinical guidelines to determine medical necessity for all authorizations.

Position Specs:

· Full Time, Benefits Eligible

· Non-Exempt 

· Hybrid: Remote & In-office (as needed/scheduled)

 Pay:

· $25 - $37.50 per hour, or competitive compensation

Preferred:

· Fluent Bi-/Multi-Lingual preferred, but not required.

Some major duties and responsibilities include:

· Comply with UM policies and procedures, annual review of UM policies, and may take part in policy and procedure creation

· Follows in-patient and out-patient cases

· Review and screen incoming service referral requests for medical appropriateness using medical necessity and benefits criteria for the various product lines, daily production, standard of minimum 50-75 referrals/day with accuracy and quality; and present appropriate cases to Medical Director for potential denial determinations while adhering to regulatory timeframe standards.

· Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria; presents cases to Medical Director for potential denial determinations

· Troubleshoots authorization/referral calls, emails, and urgent faxes within CMS guidelines

· Utilize clinical skills to coordinate, document and communicate all aspects of the precertification and utilization/benefit management program.

· Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meets criteria and can be authorized by UM staff.

· Gathers clinical information and the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for precertification process.

· Act as clinical resources to referral staff and make appropriate referrals.

· Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.

· Communicates with health plans/providers/members and other parties to facilitate member care/treatment and to assist in making decisions for the precertification process.

· Review claim/referral appeals and unauthorized claims, forwarding them for medical director/UMC review and determination when appropriate.

· Work closely with Claims Manager on overlapping issues such as rates and procedures/CPT codes for new procedures.

· Identifies potential TPL/COB cases, investigates TPL/COB issues, and notifies the appropriate internal departments.

· Identify and suggest process and system improvements that improve the goal of providing a positive, exclusive member marketing experience.

Education:

· Active and Valid RN License or LVN License in California.

Experience:

· 2 years health plan, IPA or MSO experience in management.

· Experience with clinical issues, clinical guidelines, case management and managed care.

· In-patient and Out-patient experience.

· Working knowledge of IC, DHS, DMHC, NCQA, and CMS Standards.

Skills/Knowledge:

· Strong analytical and critical reasoning, communication, and customer service skills

· Good presentation, verbal and written communication skills, and ability to collaborate with co-workers, senior leadership and other management, as well as members and business affiliates

· Ability to prioritized and organize multi-faceted/multiple responsibilities, time manage and prioritize in a fast paced, changing environment while meeting deadlines and turnaround time requirements.

· Proficient with Microsoft applications, QuickCap, EZCAP, and crystal reports, preferred

· Must be able to work independently utilizing all resources available while staying within the boundaries of duties.

· Detail-orientated and ability to work autonomously and in a team.

· Ability to time manage and prioritize duties and responsibilities.